In Consultation

Talking on the Edge: Assessing the risk of suicide

By Douglas Flemons

Q:I feel unprepared to make a proper suicide assessment with my clients. I’m nervous that I’ll neglect to ask, or the client won’t tell me, something vital to making the right clinical decision. Can you recommend an objective measure for reliably determining suicidality?

A: Suicide assessment is a high-stakes process infused with uncertainty, so your desire to find an assessment instrument to help with your decision-making is understandable. However, even the best scales can be unreliable when they’re completed in the midst of an emotional crisis. Thus, rather than outsourcing your decision-making to an instrument, I recommend that you learn how to conduct a conversational evaluation that builds on your therapeutic skills. While most clinicians already know to ask whether a client has an intent to die, a suicide plan, or access to a means for carrying it out, it’s important to go beyond simply posing these questions to get a fuller picture of the client’s risk of suicide.

Effective suicide assessments are built on a foundation of empathic connection. When clients feel heard, understood, and respected, they’re likelier to let down their guard and explore sensitive topics. In broaching such topics, the best way to protect them from feeling grilled is to intersperse your questions with empathic statements, such as “Sometimes your obligations feel impossible to meet,” or “It sounds exhausting to have to fend off intrusive thoughts of taking your life all the time.”

To help guide your assessment dialogue, my colleague, psychiatrist Len Gralnik, and I have identified four broad categories of inquiry:

Disruptions and demands—such as the loss of a relationship or social and financial status, overwhelming expectations and obligations, legal entanglements, and instances of abuse, bullying, or other traumas.

Troubling behaviors—those that increase the danger of a client’s situation, such as withdrawing from activities and other people, engaging in substance abuse or disordered eating, acting impulsively or compulsively, and harming oneself or others.

Desperation—which encompasses many of the most urgent indicators for concern, such as hopelessness, an intense desire for relief, an intent to die, a plan for making a suicide attempt, a history of making one or more attempts, or making preparations for a future attempt.

To get a deeper sense of whether clients are in imminent danger of making a suicide attempt, you must obtain a clear view not only of the likelihood that they’ll act on their desperation, but also of their resources for making it through the crisis. To this end, you’ll want to explore intra- and interpersonal sources of resilience, protective beliefs, exceptions to problems, past successes, current skills, and effective strategies for dealing with stressors. For example, I once saw a former college football player whose game-hardened ability to keep moving forward, regardless of injuries and pain, served as a source of resilience when he felt like succumbing to suicidal thoughts. Also, some of my deeply religious clients have been protected by their faith’s prohibitions against suicide. I can almost always find some degree of variation in my clients’ desperation. If there are times when they feel more overwhelmed and depressed, that means there are times when they feel less so.

However, when you make note of your clients’ resources, take care not to appear overly impressed by their resilience or the support that’s available to them. To them, life is hopeless, so straightforward optimism on your part will likely be slapped away as irritating naivety. Instead, it’s helpful to adopt a casual manner when making resource-based inquiries and noting any positive discoveries. For example, you could say to my client who’d played football, “So when you were playing college ball, you didn’t let the pain slow you down? Have you always had that kind of strength and determination, or was it something you learned? How’s that coming into play these days?”

Some clinicians routinely use boilerplate no-harm or no-suicide contracts, hoping to secure a troubled client’s commitment to live and lessen their own legal exposure if the client were to end up completing suicide. Research has shown, however, that signing such contracts doesn’t afford the client any added protection; and when sued, clinicians who use contracts don’t fare any better in the courtroom.